Our series on contact lens fees continues to generate a lot of reader interest, so
I'll continue to publish some interesting questions.

Q. Part A. What do you do when a patient comes in for his yearly exam and
states "I do not want to be fit for contact lenses today because I'm using my
insurance benefits for new glasses only"? (As is often the case, the plan covers
glasses or CLs BUT NOT BOTH!!!). Then the patient usually
comments..."besides I still have two more boxes of contacts at home and I feel
like I'm seeing fine with them".

Part B. Then the patient calls two months later and either wants to order more
contact lenses from my office or worse, wants me to give him a prescription he
can fill at a mail order company. How do I handle this with out angering the
patient??? Remember I did not do a contact lens evaluation or fitting and did not
charge for that because he specifically requested me not to do so at the annual
exam. These are always sticky situations that I am sure docs everywhere run
into.

A. My answer to part A is to only provide the services the patient wants, but
educate him about the consequences of his choice. It appears we are talking
about an established patient, so during the pretest work-up my technician would
inquire about the contact lenses. If the patient said he did not want to have the
contact lens evaluation, the tech would comply with that request, but would also
say that the contact lens Rx is expired (or will expire on ___), and that we can't
renew the prescription without doing additional tests. If the patient wants to
come in on another day for the CL evaluation that would be fine (cost could be an
issue right now for the patient), or perhaps he is considering not wearing contacts
any more. At that point in the discussion with the technician, some patients will
elect to have the CL evaluation performed now after all, and some may still want
the exam only. It's the patient's choice, but at least he's informed. The record
should be documented.

The issue created in part B of your question should have been prevented by
handling part A as indicated. The patient might act like he did not know a CL
evaluation was required, but of course, we would know better. And if he did act
like he didn't know, my office would not make an issue of that, but would simply
inform the patient that his contact Rx is expired and that the doctor needs to do a
few tests before it can be renewed. We will stand firm on needing the CL
evaluation to renew an Rx, but we'll assist the situation by helping the patient
obtain an appointment quickly and in other ways. See the question below for
more on how to handle a request for more contacts after the Rx has expired.

Q. My dilemma with contact lens fits involves two areas - patients showing up
after running out of contacts and expecting their prescription and expecting not to
be charged for their trials and how to handle a red eye during the fitting process.
I have had two red eye cases and both patients expected the fitting fee to cover it
and threatened to leave the practice if it didn't.

A. Responding to patients who need more contact lenses after the Rx is expired
is a frequently encountered issue in most practices. We've all learned from
experience that patients feel passionately about this issue, and my business
sense tells me to listen carefully when patients display passion. My professional
fees and lens prices are far from the lowest, so I really want to go above and
beyond in other areas of service because that's how I intend to attract patients
and build loyalty.

I have a practice philosophy that is based on an obsession for excellent customer
service (I use customer here rather than patient to emphasize the non-clinical
aspect of service). Most eye care professionals think they are good in the area
of customer service, but it can quickly break down if there is a cost involved or if
staff members play a large role. In my view, ECPs tend to focus too much on
small costs often creating a much larger loss. Staff members don't have the
judgment and authority of the doctor, so they stand firmly on the rules they were
taught; sometimes too firmly.

The last thing I want is an angry patient because he ran out of lenses and my
staff wouldn't let him have any more. Of course, that would be the patient's
perception and patients often don't understand the eye health aspects of contact
lens wear, but it's important to realize that the patient's perception is all that really
matters when it comes to success in practice.

That was a long warm up to my answer to the question, but here it is. My
receptionist would tell the patient that the CL Rx has expired and that a new
exam is needed for the doctor to renew it. Patients may not like hearing this
answer, but I know they understand the concept because it is analogous to any
other medical prescription. Once we've shared that news, my staff's job is to
help the patient in any way possible to get them more contacts with maximum
convenience. We should find out how many more lenses the patient has, or how
much more wearing time we have to work with. We should offer an appointment
within the next day or two so he can get the needed exam. Once the patient
agrees to schedule the exam, we should offer to provide replacement lenses in
some convenient manner if needed to get the patient to the exam time. This
could be in the form of a free trial lens or perhaps selling him a box of lenses with
an open box exchange offer if the CL Rx is found to have changed at the exam.

Are you shocked at the idea of offering to exchange an open box of lenses that
might only have five lenses inside? Don't be. Think bigger. That is the kind of
gesture that wins great patient loyalty! What a fantastic practice to do business
with! The patient would feel like his needs were all you cared about, and that's a
great feeling. OK, let's think about the cost... first, how many patients would you
really have to make such an offer for... second, what percentage would not need
an Rx change anyway? Of the remaining group, how much is your cost on a box
of lenses? If that amount is a big concern it tells me that your professional fee
basis is set too low. You could raise your CL evaluation fee for everyone by the
average cost of two boxes of lenses and no one would likely notice at all.

Let's go further - what could you do for the toric or bifocal patient? That cost
may be too much to absorb, but most of us have trial lenses that would be close
to the needed Rx. But what if you did not have the exact Rx? Your staff could
probably not do much in that situation alone, but the doctor could. A close Rx is
better than no Rx in many cases. A -7.00 sphere in one eye could help a patient
who needs -6.00 -2.00 X 180 get by for a few days. Be creative. How could you
help if you really wanted to? What would you do if the patient was your spouse
or sibling?

Some ECPs might wonder why they should jump through hoops when the patient
should have noticed he was getting low on his supply of lenses or should have
responded when he received a recall notice from the office. I think that's an
example of a doctor not thinking like a business person. We need to be
business-savvy if we want to build successful practices, and business-savvy
CEOs understand human nature and don't try to teach lessons. They find a need
and fill it.

Let's also get a grip on the reality of eye health risks in contact lens wear. Most
of the cases which we stand firm against releasing more contact lenses are
patients we examined and prescribed for less than two years ago. Because
these patients want more lenses, chances are quite good they are seeing pretty
well and have eyes that are healthy. Granted, I don't know that for sure on any
given case, but helping patients for a short period of time until I can perform the
needed exam does not carry much risk. Let's compare it to a patient you are
treating for glaucoma who does not show for a scheduled exam and calls up
needing a refill on his medication. He tells your staff that he is all out of drops,
and can't get in to see you for at least a week. I'm likely to stress the importance
of the exam, but I'll call the pharmacy with one more refill to give this patient the
care he needs until he can get in to see me. I wouldn't keep prescribing the drug
forever without an exam, but one grace period is better than no treatment. And
that's how I handle a drug Rx for a pair of eyes that I know is sick! I can't see a
tougher policy on CL Rxs than glaucoma.

As for the red eye cases, I would design my fitting service to cover a set period of
time, like two months from the lens dispensing, and I'd take care of anything that
occurred during that period. Why not consider red eyes a part of that global
care? I think you'd be hard pressed to assume that the contact lenses did not
play some role in the etiology and it would be even harder to convince the
patient. Of course, if you were concurrently treating other conditions while fitting
contact lenses, additional tests would not be included in the fitting fee (like visual
fields or nerve fiber analysis for example), but that would be explained at the time
of the eye exam and it would be pretty rare. I would just take care of anything
else. If you don't feel you would be compensated enough to care for red eyes
during the fitting period, raise your fitting fee.